Margonis Georgios Antonios, Vauthey Jean-Nicolas
Department of Surgery Memorial Sloan Kettering Cancer Center New York New York USA.
Department of General and Visceral Surgery Charité Campus Benjamin Franklin Berlin Germany.
Ann Gastroenterol Surg. 2022 Jun 27;6(5):606-615. doi: 10.1002/ags3.12591. eCollection 2022 Sep.
Precision surgery for colorectal liver metastases (CRLM) includes optimal selection of both the patient and surgery. Initial attempts of using clinical risk scores to identify patients for whom technically feasible surgery is oncologically futile failed. Since then, patient selection for single-stage hepatectomy followed three distinct approaches, all of which incorporated biomarkers. The V600E mutation, the G12V variant, and the triple mutation of , and appear to be the most promising, but none can be used in isolation to deny surgery in otherwise resectable cases. Combining biomarkers with clinicopathologic factors that predict poor prognosis may be used to select patients for surgery, but external validation and matched analyses with medically treated counterparts are needed. Patient selection for special surgical procedures (two-stage hepatectomy [TSH], Associating Liver Partition and Portal vein Ligation for staged hepatectomy [ALPPS], and liver transplant [LT]) has been recently refined. Specifically, mutations and right-sided laterality have been proposed as separate contraindications to LT. A similar association of right-sided laterality, particularly when combined with mutations, with very poor outcomes has been observed for ALPPS and has been suggested as a biologic contraindication. Data are scarce for TSH but mutations may portend very poor survival following TSH completion. The selection of the best single-stage hepatectomy (optimal margin and type of resection) based on biomarkers remains debated, although there is some evidence that may play a significant role. Lastly, although there are currently no criteria to select among the three special techniques based on their efficacy or appropriateness in different settings, mutational status may be used to select patients for TSH, while right-sided tumor in conjunction with a mutation may be a contraindication to LT and ALPPS.
结直肠癌肝转移（CRLM）的精准手术包括对患者和手术的最佳选择。最初尝试使用临床风险评分来识别那些技术上可行但肿瘤学上无意义的手术患者，但未成功。从那时起，单阶段肝切除术的患者选择遵循三种不同的方法，所有这些方法都纳入了生物标志物。V600E突变、G12V变体以及 、 和 的三重突变似乎最有前景，但在其他可切除的病例中，没有一种可以单独用于拒绝手术。将生物标志物与预测预后不良的临床病理因素相结合，可用于选择手术患者，但需要外部验证以及与接受药物治疗的对照进行匹配分析。最近，特殊手术程序（两阶段肝切除术[TSH]、联合肝脏分隔和门静脉结扎分期肝切除术[ALPPS]以及肝移植[LT]）的患者选择已得到完善。具体而言， 突变和右侧性已被提议作为LT的单独禁忌症。对于ALPPS，也观察到右侧性，特别是与 突变结合时，与非常差的结果存在类似关联，并已被提议作为生物学禁忌症。关于TSH的数据很少，但 突变可能预示TSH完成后生存率非常低。基于生物标志物选择最佳的单阶段肝切除术（最佳切缘和切除类型）仍存在争议，尽管有一些证据表明 可能起重要作用。最后，尽管目前没有基于三种特殊技术在不同情况下的疗效或适用性进行选择的标准，但 突变状态可用于选择TSH患者，而右侧肿瘤与 突变结合可能是LT和ALPPS的禁忌症。
